Escolar Documentos
Profissional Documentos
Cultura Documentos
Journal of
Bodywork and
Movement Therapies
www.intl.elsevierhealth.com/journals/jbmt
COMPARATIVE STUDY
Department of Physical Therapy, Faculty of Associated Medical Sciences, Khon Kaen University,
Khon Kaen 40002, Thailand
b
Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University,
Khon Kaen 40002, Thailand
c
Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Khon Kaen University,
Khon Kaen 40002, Thailand
d
Faculty of Public Health, Khon Kaen University, Khon Kaen 40002, Thailand
Received 2 November 2004; received in revised form 3 February 2005; accepted 5 February 2005
KEYWORDS
Massage;
Traditional Thai
massage;
Myofascial trigger
point;
Back pain;
Randomized control
trial
Summary The aim of this study was to verify the effectiveness of traditional Thai
massage (TTM) among patients with back pain associated with myofascial trigger
points (MTrPs). Swedish massage (SM) was selected as the treatment for the
comparison group. One hundred and eighty patients were randomly allocated to
receive either TTM or SM for 6 sessions during a 34 week period, with follow-up 1
month later. Results indicated that pain intensity, assessed using the visual analog
scale (VAS), among patients in both groups was reduced by more than half after 3
weeks of treatment and for up to one month afterwards (Po0:05) with no significant
difference in VAS between the groups. Similar improvements were found for most
other outcome measures. We conclude that TTM and SM are effective in reducing
back pain among patients with MTrPs. We therefore suggest that massage therapy,
and in particular Thai massage, be considered as an alternative primary health care
treatment for this disorder.
& 2005 Elsevier Ltd. All rights reserved.
Background
Corresponding author. Tel./fax: +66 43 202085.
1360-8592/$ - see front matter & 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbmt.2005.02.001
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Effectiveness of traditional Thai massage versus Swedish massage among patients
diagnosed and well-documented source of back
pain. Finding effective treatments for back pain
from MTrPs is a challenge that is currently being
given much attention by allied health professionals.
The popularity of alternative medical treatment for
many conditions has increased during recent years
and massage has been documented as one of the
most frequently used alternative treatments for
back pain (Eisenberg et al., 1998).
The ultimate goals of massage therapy for MTrPs
are to deactivate the trigger points, eliminate pain,
restore normal tissue mobility, and improve function. The overall success of massage therapy in
being able to achieve these goals is difficult to
assess because of various confounding variables,
including the many differences in massage technique, which use different maneuvers and varying
amounts of pressure.
A summary by Rachlin (1994) indicated that,
although some types of superficial massage, such as
those consisting of stroking and kneading, are good
for general relaxation, massaging the area of
reported pain without trying to find and eradicate
the trigger point will not provide the patient with
lasting relief. This reported lack of long-term
effect from such types of massage may be due to
the application of insufficient pressure to deactivate trigger points and break down adhesions.
However, it has also been found that some forms of
deep massage (deep friction, compression, ischemic compression) have produced side-effects
such as post-massage soreness and ecchymosis
when applied to the trigger point specifically, with
no accompanying treatment of the surrounding
back muscles (Rachlin, 1994; Simon et al., 1999).
A combination of deep and superficial massage
for more effective treatment of MTrPs was therefore suggested by Rachlin (1994). The recommended technique consists of an initial period of
Swedish massage (SM)-like techniques, including
stroking, kneading and stripping, to warm the
tissue and make it more elastic, after which the
practitioner is more able to apply increased
pressure, such as friction massage, deep into the
muscle with reduced discomfort for the patient.
This combination of superficial and deep massage
appears to be effective in the relief of back pain
from MTrPs, however it requires highly skilled
practitioners and is time-consuming in terms of
treatment time for the patient.
A similar, but less complex and possibly more
practical, choice of treatment may be traditional
Thai massage (TTM). The technique of TTM is
considered as a form of deep massage, however,
the pressure applied during TTM is believed to be
gentler than that applied using other deep massage
299
Methods
Design and setting
This prospective, parallel group, randomized clinical trial was conducted in the Department of
Physical Therapy, Faculty of Associated Medical
Sciences, Khon Kaen University, Thailand. The
ethical committee of Khon Kaen University approved the research protocol.
Participants
Potential participants, aged 2150 years, were
recruited through public announcement broadcasts
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300
by local radio stations and through flyers posted
around the city of Khon Kaen, during a 10 month
period between August 2003 and May 2004. These
recruitment announcements called for individuals
who had experienced persistent back pain, either
sub-acute (lasting for 412 weeks) or chronic
(lasting for over 12 weeks), to volunteer to take
part in the study. Subjects for inclusion in the study
were primarily selected by a Physical Therapist. In
cases where there was doubt about eligibility for
inclusion, a confirmatory examination was conducted by a Physical Medicine and Rehabilitation
doctor. Baseline data were collected from all
eligible individuals who responded to the announcements.
The clinical criteria for the diagnosis of MTrPs
in this study were a modification of that specified by Travell and Simon (1983). The inclusion
criteria were that patients had experienced spontaneous back pain for longer than 4 weeks and that
at least one trigger point was present in the upper
and/or lower torso region. Trigger points were
diagnosed as the presence of focal tenderness at a
palpable nodule in a taut band and with pain
recognition.
Even if subjects met the above criteria, individuals were not included if they had at least
one of the following conditions: menstruation,
pregnancy, or a temperature of more than 38.5 1C
on the day of examination; a history of acute
trauma, back-surgery, spinal fracture, joint
subluxation or instability, inflammatory joint
disease (rheumatoid arthritis or gout), muscle
disease, malignancy or infection; or evidence of
neurologic deficit, multiple sclerosis, hemi/paraparesis or myelopathy, skin diseases, or infectious
diseases (tuberculosis or AIDS). In addition,
if any individual was considered to be unable
to commit to the full course of treatment and
follow-up they were also excluded prior to the start
of the study.
Informed consent was obtained prior to the
baseline examination
Procedure
Randomization
There were 180 patients who met the above
inclusion/exclusion criteria and they were randomly allocated to one of the two treatment arms
using block randomized allocation with block sizes
of 2, 4, and 6. Groups were assigned using a pregenerated random assignment scheme enclosed in
envelopes, which resulted in a total of 90 patients
per group.
U. Chatchawan et al.
Treatment
All eligible patients received one of two treatments, either TTM or SM, during six sessions over a
period of 34 weeks. For the majority of patients,
treatment occurred according to the planned
schedule of two sessions a week for 3 weeks.
Patients who could not complete the treatment
program within 4 weeks were excluded from the
trial (see Fig. 2 for details of patients who did not
complete the study). Treatment was given for
30 min and followed by 10 min of passive stretching,
which was similar in both groups.
Stretching exercises were included since they are
an integral part of TTM. Stretching was also
included after SM to maintain comparability of
the groups and also for ethical reasons, since the
literature suggests that stretching the muscle after
treatment for MTrPs provides longer-term pain
relief (Travell and Simon, 1983; Jaeger and Reeves,
1986; Hanten et al., 2000). Both forms of massage
treatment were given by one of three massage
therapists who had 4, 8 and 20 years, respectively,
of experience in TTM. Although each patient
received the same type of massage at each visit,
the massage therapist was not always the same
person for each patient. Each massage therapist
was trained in both TTM and SM for at least 3
months prior to the study so that they all had the
same standard of practice in both forms of
massage. Training was given by one physical
therapist who had 15 years of physical therapy
experience and more than 10 years of TTM
experience, with certification from the Institute
of Thai Traditional Medicine, Department of Medical Services, Ministry of Public Health. At the end
of the training period, each massage therapist was
tested by the trainer, until the therapists were
considered to be similar in terms of the differential
degree of pressure applied for SM and TTM (the
trainer started to feel some pain (SM) or the
trainers pain threshold was reached (TTM)) and in
how they followed the expected steps for both
massage techniques.
In keeping with the recommendation of Khon
Kaen Universitys ethical committee, patients in
both groups were given verbal and written information at the start of the study about a recommended
home care program, which consisted of back
stretching exercises and health care education
(correct posture and lifting techniques).
Assessments
All outcome measures were assessed by one
physical therapist with 15 years of experience, for
whom the treatment groups were blinded. The
reliability of outcome measures (such as the pain
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Effectiveness of traditional Thai massage versus Swedish massage among patients
intensity, the range of motion of the thoracolumbar
spine in all directions, body flexibility, and the
pressure pain threshold (PPT)) was tested on 30
patients with back pain associated with MTrPs prior
to data collection. All outcome measures showed a
very high degree of correlation (Intraclass Correlation Coefficient (ICC) over 0.95).
To evaluate the immediate therapeutic effectiveness of the massage treatments, all outcome
measures were assessed immediately before and
after the first treatment on day 1. To evaluate the
short-term effects during the intervention period,
all outcome measures were assessed before and
after the second and the third week of treatment
(just before the fifth treatment and a few days
after the sixth treatment respectively). To evaluate
the long-term effectiveness of the intervention, all
patients returned for follow-up assessment one
month after the last treatment.
Interventions
Traditional Thai massage
TTM in this study was performed according to the
system of royal Thai massage, which applies the
theory of 10 Sens, based on the concept of
invisible energy lines (Sens) running through the
body (Tapanya, 1993). Massage points included in
this method are located along two lines and at an
additional, single, point on each side of the back
(Fig. 1). The first line of massage starts from a point
2 cm above the posterior superior iliac spine (PSIS)
and ends at the thoraco-cervical junction or C7.
Each point on this line is approximately one finger
breadth away from the spinous process. The second
line follows the same course but is about two finger
301
Swedish massage
The SM treatment was performed using body-oil
(jojoba oil) for lubrication of the skin. Pressure was
applied on the area of the back between PSIS and
C7. This pressure was enough to reach deep into
the skin and subcutaneous tissue, but was not
sufficient to reach the pain threshold of each
patient. SM techniques used in this study included
light stroking or effleurage, and petrissage (which
consist of kneading with the thumb, digit, and
palm; wringing and skin rolling).
Outcome measures
Each patients demographic characteristics and
medical history were recorded. Clinical outcomes
were grouped as patient-rated outcome measures
and as back performance measures. All outcomes
were measured as described below
Figure 1 The massage points: running from thoraco-cervical junction or C7 to posterior superior iliac spine (PSIS) (each
point in the first line is one fingers breadth from the spinous process [1], in the second line it is two finger breadths
from the spinous process [2] and the two massage points (dark dots) are located at the level of L2, three finger breadths
from the spinous process).
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302
U. Chatchawan et al.
Back performance
Thoracolumbar spine range of motion (ROM): The
modified Schober test for ROM was used to assess
the mobility of the Thoracolumbar spine in the
directions of flexion, extension, and left and right
lateral flexion (Reese and Bandy, 2002). The
distance moved in each direction was measured
using a tape measure. The reliability of lumbar
flexion and extension for assessment among patients with low back pain has been reported to be
r 0:7820:89 for lumbar flexion and r 0:6920:91
for lumbar extension (Irnich et al., 2001; Gunn,
1996).
Body flexibility
A sit-and-reach box was used to measure body
flexibility three times. The average of the three
measurements was recorded in centimeters. The
reliability of this test for patients suffering from
back pain has not yet been reported.
Statistical analyses
Estimation of the sample size
Estimation of the sample size was based on a pilot
study (total n 30) that compared the effectiveness of TTM with that of SM for subjects with back
pain associated with MTrPs. Based on this pilot
study, a drop-out rate of 15% was allowed for in
estimating the final sample size and a standard
deviation (of VAS) of 2.2 was used to calculate the
sample size needed to detect a 1-point change of
pain (which was considered as the lowest level to
accept clinical significance of the results) with 80%
power and 5% significance. According to these
criteria 180 patients were recruited.
Data analyses
Outcome measures were analyzed as continuous
variables and presented as the mean and standard
deviation (SD). This study aimed to analyze each
outcome separately at different points of time over
the period of treatment to provide data on the
immediate, short, and long-term therapeutic effectiveness of the massage therapy. All analyses
were performed on the basis of intention-to-treat.
Paired t-tests were used to compare outcome
variables at baseline (measures taken immediately
before the first treatment) with outcome measures
at both 3 weeks and at 1 month after the last
treatment. Since the randomization method did not
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Effectiveness of traditional Thai massage versus Swedish massage among patients
Results
Randomization and progress through the
trial
Two hundred and fourteen potential subjects
responded to the recruitment advertisements and
were screened for eligibility for the study. Of these
subjects, 180 met the inclusion/exclusion criteria
and signed the consent forms to take part in the
study. Ninety subjects were randomly selected to
receive TTM and the other 90 subjects received SM.
Five subjects from the TTM group and three from
the SM group dropped out during the period of the
study. A detailed summary of patient recruitment,
participation, attrition and reasons for dropping
out from the study is shown in Fig. 2.
303
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304
U. Chatchawan et al.
Baseline Evaluation (n=214)
Randomized (n=180)
TTM(n=90)
SM (n=90)
Figure 2 Participant numbers throughout the study and reasons for dropping outs.
Discussion
The findings of this study suggest that pain intensity
(VAS) among back pain patients with MTrPs can be
reduced by over 50% after only 3 weeks of
treatment with either TTM or SM. These results
demonstrate the effectiveness of both TTM and SM
massage when followed by passive stretching.
Previous studies using a similar combination of
massage and stretching found comparable results.
For example, Hanten et al. (2000) reported a 50%
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Effectiveness of traditional Thai massage versus Swedish massage among patients
Table 1
305
Characteristics
TTM
Number of patients
90
Demographic
Age(years)
37.3 (8.8)
Gender (n (%) female)
57 (63)
Weight (kg)
57.6 (9.9)
Height (cm)
158.5 (16.6)
Exercise; n (%)
13 times a week
46 (51.1)
4 3 times a week
4 (4.5)
Occupation by physical work load; n (%)
Heavy work
7 (7.8)
Lighter work
83 (92.2)
Causes of back pain; n (%)
None or cannot remember
10 (11.1)
Carrying heavy objects
20 (22.2)
Prolonged sitting during work
32 (35.6)
Accident
2 (2.2)
Lack of exercise
6 (6.7)
Carrying heavy objects and prolonged sitting with others activities 12 (13.3)
Others causes
8 (8.9)
Duration of back pain episode (month)
36.6 (38.8)
Duration of the last episode of back pain (weeks)
6.7 (8.1)
Stress level; n (%)
Lower than normal
9 (10)
Normal
55 (61.1)
Higher than normal
26 (28.9)
Expectation of their own treatment; n (%)
To feel better or much better
90 (100)
Patient-rated outcome measure
Pain intensity (VAS 010 cm)
5.5 (1.5)
Disability (Oswestry disability questionnaire 0100 scale)
20.70 (8.9)
Patients satisfaction with treatment
n (%) (total n 86/group)
Satisfied
13 (15.1)
Very satisfied
71 (82.6)
Back performance
Thoracolumbar spine flexion (cm)
8.3 (1.7)
Thoracolumbar spine extension (cm)
5.2 (1.8)
Thoracolumbar spine left lateral flexion (cm)
19.8 (3.4)
Thoracolumbar spine right lateral flexion (cm)
18.9 (3.9)
Body flexibility (cm)
1.4 (13.2)
Pressure pain threshold (kg/cm2)
2.7 (0.9)
SM
Total
90
180
35.5 (8.8)
57 (63)
58.5 (11.7)
160.0 (13.3)
36.4 (8.8)
114 (63)
58.1 (10.8)
159.2 (15.0)
50 (55.6)
5 (5.5)
96 (53.3)
9 (5.0)
2 (2.2)
88 (97.8)
9 (5)
171 (95)
6 (6.7)
23 (25.6)
40 (44.4)
1 (1.1)
6 (6.7)
9 (9.9)
5 (5.6)
34.8 (35.6)
5.2 (5)
16 (8.9)
43 (23.9)
72 (40.0)
3 (1.7)
12 (6.7)
21 (11.7)
13 (7.2)
35.7 (37.1)
5.9 (6.7)
10 (11.1)
58 (64.4)
22 (24.4)
19 (10.6)
113 (62.8)
48 (26.7)
89 (98.9)
179 (99.4)
5.2 (1.7)
20.73 (8.4)
5.4 (1.6)
20.7 (8.6)
11 (12.8)
74 (86.1)
24 (14)
145 (84.3)
8.4 (1.6)
5.0 (5.5)
19.0 (4.8)
18.2 (4.1)
1.5 (9.9)
2.6 (1.0)
8.3 (1.6)
5.1 (4.1)
19.4 (4.2)
18.5 (4.0)
1.5 (11.7)
2.7 (1.0)
Note: All continuous characteristics are reported in mean (SD), etc. age, weight, height, etc.
All category characteristics are reported as number (percentage), gender, exercise, stress, etc.
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U. Chatchawan et al.
Table 2 Patient-rated outcome measures and back performance outcome measures at all assessment time
points during the 3 weeks of intervention and at 1 month post-final treatment.
Outcome
Group
Baseline
Day 1
Week 3
Month 1
TTM
SM
TTM
SM
TTM
SM
TTM
SM
5.5 (1.5)
5.2 (1.7)
NA
2.2 (1.9)
2.0 (1.7)
88
82
12
10
13.8 (8.8)
15.4 (9.1)
2.4 (1.9)
2.5 (2.0)
NA
20.7 (8.9)
20.7 (8.3)
4.1 (1.9)
3.4 (1.9)
83
86
9
10
NA
NA
TTM
SM
TTM
SM
TTM
SM
TTM
SM
TTM
SM
TTM
SM
8.3 (1.7)
8.4 (1.6)
5.2 (1.8)
5.0 (5.5)
19.8 (3.4)
19.2 (4.4)
18.9 (3.9)
18.2 (4.1)
1.4 (10.5)
1.3 (9.8)
2.7 (0.9)
2.6 (1.0)
8.5 (1.6)
8.4 (1.6)
5.3 (1.9)
5.1 (4.4)
19.9 (3.5)
19.4 (4.2)
19.5 (3.8)
19.0 (3.7)
2.5 (9.8)
2.4 (9.0)
3.0 (1.3)
2.8 (1.2)
8.5 (1.8)
9.3 (8.6)
5.6 (2.0)
5.1 (2.8)
20.0 (3.6)
19.3 (3.8)
19.6 (4.0)
19.4 (3.9)
3.6 (9.6)
3.7 (1.9)
3.5 (1.4)
3.4 (1.5)
NA
Patient satisfaction
Very satisfied (%)
Having side effects, n (%)
(soreness after treatment)
Disability (ODQ), 0100 scale; mean (SD)
Back performance: mean (SD)
Thoracolumbar spine flexion (cm)
Thoracolumbar spine extension (cm)
Thoracolumbar spine left lateral flexion (cm)
Thoracolumbar spine right lateral flexion (cm)
Body flexibility (cm)
Pressure pain threshold (kg/cm2)
NA
NA
13.4 (10.1)
13.9 (8.9)
NA
NA
NA
NA
4.2 (1.3)
3.6 (1.5)
Note: TTM is traditional Thai massage and SM is Swedish massage. ODQ Oswestry Disability Questionnaire, NA not
available.
Significant improvement (decrease in VAS and ODQ, increase in back performance) from baseline levels (Po0:05).
Comparison of the adjusted mean and 95% CI of outcome measures (adjusted for baseline using ANCOVA) at each assessment time point.
Outcome
4.0
3.6
Difference
(95% CI)
Pvalue
TTM
0.4
(0.0 to 0.9)
0.05
2.2
2.0
13.7
15.3
Disability (ODQ)
Back performance
Thoracolumbar spine
flexion (cm)
Thoracolumbar spine
extension (cm)
Thoracolumbar spine
left lateral flexion
(cm)
Thoracolumbar spine
right lateral flexion
(cm)
Body flexibility (cm)
Pressure pain
threshold (kg/cm2)
8.6
8.4
5.2
5.1
19.7
19.6
19.28
19.25
2.43
2.46
3.0
2.9
0.2
(0.1 to 0.5)
0.1
(0.9 to 1.1)
0.1
(0.6 to 0.9)
SM
Difference
(95% CI)
Pvalue
TTM
SM
Difference
(95% CI)
P-value
0.2
(0.4 to 0.7)
1.6
(3.9 to 0.6)
0.56
2.4
2.6
0.2
(0.8 to 0.4)
0.6
(2.4 to 1.1)
0.51
0.16
13.4
14.0
0.7
(2.5 to 1.1)
0.5
(0.2 to 1.2)
0.4
(0.5 to 1.3)
0.46
NA
0.14
NA
0.38
NA
0.20
8.5
9.2
0.81
5.6
5.1
0.80
19.9
19.5
0.02
(0.6 to 0.7)
0.95
19.4
19.6
0.2
(1.1 to 0.7)
0.71
NA
0.03
(0.8 to 0.7)
0.1
(0.1 to 0.3)
0.94
3.5
3.8
0.68
NA
0.39
3.5
3.4
0.3
(1.5 to 1.0)
0.1
(0.3 to 0.4)
0.68
4.1
3.7
0.4
(0.2 to 0.7)
0.47
0.00
Note: TTM is traditional Thai massage and SM is Swedish massage. ODQ Oswestry Disability Questionnaire, NA not available.
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Patient-rated
outcome measure
Pain intensity (VAS)
SM
Table 3
307
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308
U. Chatchawan et al.
Pain Intensity
(VAS score)
8.0
TTM
7.0
SM
6.0
5.0
4.0
3.0
2.0
1.0
0.0
Pretest
Visit (week)
Conclusion
Based on the results of this study, we conclude that
TTM or SM treatment can be used, with equal
expected effectiveness, in the treatment of back
pain associated with myofascial trigger points. We
therefore recommend that TTM and SM be more
widely promoted as alternative primary health care
treatments for this disorder.
Acknowledgements
This study was supported by a study grant from the
Office of the Higher Education Commission, Ministry
of Education, Thailand.
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The similarity between the effects of SM and TTM
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significant. It was difficult to compare our study
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randomized control trial with independent (unbiased) group allocation and intention-to-treat
methodology. There was a high compliance rate,
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